Medical Notes/summariser

2 weeks ago


Wolverhampton, United Kingdom Prestbury Medical Practice Full time

**Job Summary**: The Practice is moving towards becoming a paper-light environment, the main responsibilities of the post-holder are for the day to day supervision and management of all medical records summarising staff ensuring that notes are summarised and read coded with relevant information from patients clinical records into the Practice computer system, working strictly in accordance with the Practice notes summarising protocol. Main Duties/Key Tasks: Induction and training of all new staff to agreed standards Ensure adequate staffing levels to maintain workflow any shortfalls report to practice Manager. Culling and sorting patient records and letters in preparation for summarising. Reviewing medical records and producing an accurate summary of the patients medical history.

Read Coding the information into the Practice clinical system Auditing data collection standards in the Practice Monitoring progress of notes summarising against Practice targets Monitoring patient call and recall systems Filing and retrieving paperwork Practice Values To demonstrate and provide evidence of the Practice Values, these are: - Provide a professional service - Working together as one - Respect for each other Confidentiality: In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. They may also have access to information relating to the Practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Practice policies and procedures relating to confidentiality and the protection of personal and sensitive data To ensure the safety and security of patient records or data by storing them in a lockable cabinet or cupboard when no longer required or at the end of your working day.


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